Breakthrough Lousiville Parent Application

Parent / Guardian Application
Checklist of forms needed to complete the application process:
 Student Statement
 Parent / Guardian Statement
 Counselor Form
 2 Academic Teacher Reference Forms

You will be notified by phone or email if your application is not complete.
Child or Children Applying*
Parent / Guardian Name*
Child's Current Grade
Child's School Your Attending
Child's School this Fall (if different)
Type of Parent / Guardian

GuardianMotherFather
Parent / Guardian Address*

Street Address

Street Address Line 2

CityState

Zip Code
Daytime Phone
Mobile Number
Email*
Marital Status
Emergency Contact Name
Emergency Contact Phone Number

Area CodePhone Number
With whom is the child living with?
Income

Please complete the following.
Please check the appropriate income level for the household in which the student lives.

$0 - $16,910$19,911 - $31,284$31,285 - $39,461$39,462 - $47,638$47,639 - $55,815$55,816 - $63,992$63,993 - $72,169$72,170 - $80,346Other
Please list all the members of your household with their age, relationship to the applicant, and their respective education levels
Why would you like to see your child involved in Summerbridge?
Please provide any information you think would be useful for our staff to know in helping your child succeed.
Please list all the members of your household with their age, relationship to the applicant, and their respective education levels *
Transportation

Please complete the following.
Does your child need bus transportation to Summerbridge?

YesNo, I will provide transportation
If you answered yes to the previous question, please list the closest school to your house.
If there are any possible conflicts that would cause your child to miss any part of the program, please list them, here.
The Commitment

Please consider my child for the Summerbridge program. We verify that all of the information provided is correct. If accepted, we will not plan special events during the dates and times or the summer session. We understand that we will have the option of returning for a second summer if our child maintains a B average during the school year. *
Signature

Clear
Should be Empty:

Parent / Guardian Application

Income

Transportation